The Rotator Cuff

Rotator cuff injuries  are very common and is the most common cause of shoulder pain over the age of thirty.  Many rotator cuff  or shoulder *problems* do not relate to injuries per se.  Some of you here may have suffered a recent injury to your shoulder and some of you simply woke up with shoulder pain for no known reason.  Many rotator cuff problems are simply degenerative, genetic, attritional (wearing out), inflammatory or are age/activity  related.  While rotator cuff injuries can be caused by a recent trauma.  The most common cause of rotator cuff  pain is usually because of a degenerative or attritional process. Simply stated, your muscle or tendon is wearing out… like your favorite pair of blue jeans.  

 

What is the Rotator Cuff?

The rotator cuff are a series of 4 small muscles that are located around the shoulder and deep to the deltoid, a  larger and better  known muscle . These muscles coordinates the function of the shoulder by harnessing the power of the larger deltoid, pectorialis, and other muscles and turning that power into useful, well coordinated, and fluid motion.  It is very easy for the larger more powerful muscles to over-power the rotator cuff and cause over-use injuries.  This is a very common source of shoulder pain in weight lifters or those of you who are active in the gym.  When you are working out… do not ignore your rotator cuff exercises.

 Video of Rotator Cuff Injuries, Tears and Your Treatment Options

Howard Luks MD discussing Rotator Cuff Tears and their management

The Most Common Rotator Cuff or Shoulder Injuries

There are many different forms of common rotator cuff  or shoulder injuries.  The majority of rotator cuff problems we see are degenerative or attritional in nature.  Some rotator cuff problems are acute or the result of a recent accident of fall. Massive rotator cuff injuries can result from a fall and a dislocation in people over 40.  Anyone over 40 who dislocates their shoulder should consider an MRI soon after the injury, since a massive tear can occur at the time the shoulder dislocated.   Other rotator cuff problems can be secondary to another problem in the shoulder we refer to as instability.  Rotator cuff symptoms vary significantly.  Shoulder pain from rotator cuff tendinitis can be more severe than the pain from a tear — and the shoulder pain associated with a large tear may be much less than the shoulder pain experienced by someone with a small tear.    That said, most patients with the shoulder disorders mentioned below will have very similar rotator cuff symptoms.

 

Let’s discuss rotator cuff disorders and rotator cuff symptoms in more detail.

Common rotator cuff injuries include:

• Tendinosis ; The most common cause of shoulder pain
• Tendonitis
• Partial Tears of the rotator cuff
• Full Thickness tears of the rotator cuff
• Calcific Tendonitis : Calcium deposits in the rotator cuff
• Internal Impingement

 

Patients over 35 who suffer from shoulder pain tend to suffer from more degenerative problems — whereas younger patients tend to suffer more overuse type injuries, typified by tendonitis, inflammation and secondary weakness and pain.    Many young patients may also have traumatic  instability where the shoulder is loose or actually disclocates.  Traumatic rotator cuff injuries are rare in teenagers.  The pain associated with instability is usually because this causes the rotator cuff to work very hard to keep the shoulder in position and therefore your rotator cuff pain is secondary to the instability.  In this instance, to treat your rotator cuff injury, you must address the underlying shoulder instability first.

Rotator Cuff tendinosis

Symptoms from tendinosis generally come on slowly over time and reach a point where you are very uncomfortable. Some patients can identify an activity which precipitated the onset of pain, but most do not know what caused their symptoms to appear.  One of the hallmarks of rotator cuff tendinosis is terrible night pain. The pain is usually on the side, and occasionally on the front of the shoulder.    Patients with tendinosis typically do not have weakness.  They may have weakness which is secondary to pain (and you simply do not want to use the arm), but they do not have true weakness like that associated with a large rotator cuff tear.  Snapping or popping in the shoulder may occur because the rotator cuff is no longer smooth,   Patients with tendinosis  may have pain when lifting their arm in certain positions, and loss of motion may occur.  Pain is usually along the side of your upper arm and some people describe the pain as radiating down towards their elbow. Patients with tendinosis have trouble putting on a coat, putting on a bra, trying to reach up high or reach behind their back. Many many years ago, the shoulder pain associated with tendinosis was attributed to rotator cuff “impingement”, Impingement syndrome or Rotator Cuff Syndrome.  

If you surgeon mentions that you have rotator cuff impingement, Impingement Syndrome or Rotator Cuff  Syndrome — you are more than likely suffering from rotator cuff tendinosis or a partial tear or fraying of the rotator cuff.  Rotator cuff impingement theorists also used to believe that a *bone spur* caused most rotator cuff problems.  Most academic surgeons no longer believe that rotator cuff impingement or tears are due to bone spurs around the shoulder.  If you are told you require shoulder surgery because of a bone spur… you should quickly seek a second opinion!

Overuse Rotator Cuff tendinitis

Overuse tendinitis typically occurs in patients who participate in certain sports.  Pitchers, swimmers or volleyball players with shoulder pain the day after they played is a common presentation.  Their pain is mild to severe.  Their pain is usually along the back or side of the shoulder and responds well to rest and anti-inflammatories.   Some of these patients (especially overhead athletes) can have overuse rotator cuff like pain, but the actual cause is that the shoulder is loose or unstable and the rotator cuff is working too hard to maintain the shoulder joint in its proper positon.   Some overhead athletes also have a condition known as Internal Rotator Cuff Impingement and this can present as a case of rotator cuff tendinitis, but the actual cause of pain is “micro”-instability (where the shoulder is loose, but doesn’t actually dislocate).

Rotator cuff tendinitis can also be caused by secondary factors such as nearby bursitis or calcific tendonitis (read further).

 

Rotator Cuff tears…

Rotator cuff tears are surprisingly common.  Many patients have tendon tears and do not even know it.  Many rotator cuff tears are attritional, and are not the result of a single injury to the tendon.  This means the tendon simply wore out over time.  Some rotator cuff injuries or tears occur because of trauma and are termed acute.  If you are over 50 you have over a 25% chance of having a rotator cuff tear!  Even without pain!  That is why we as physicians need to treat patients and not MRI findings.  The rotator cuff tear may NOT be the source of your pain.   Too many surgeons are too quick to pull the trigger on recommending surgery just because an MRI found a tear.    Jim Andrews, a very famous sports medicine physicians to many professional athletes found that over 90% of MRIs in pitchers with NO SHOULDER PAIN had tears and other abnormalities which would normally lead to a recommendation for surgery.   Why do some rotator cuff tears lead to pain and others do not… we don’t know!.

 Partial thickness rotator cuff tears….

 Partial thickness rotator cuff tears are very common and unless your pain has not improved with non-operative treatment, are rarely an indication for surgery. The rotator cuff is very thick and partial tears occur when a portion of the rotator cuff pulls away from its attachment to the bone.  Most patients with partial thickness rotator cuff tears will present in a manner similar to patients who suffer from tendinosis—and in many situations, the treatment is very similar.  Most patients with tendinosis, and partial tears will improve with rest, ice, medication, physical therapy or an occasional injection. Their most common complaint is pain with lifting the arm overhead — and they will also, typically have severe pain at night.

Full thickness rotator cuff tears…

Full thickness or complete tears are also fairly common.  Many tears are attritional or degenerative, while some are acute, or the result of a fall or accident.   Attritional tears are similar to your favorite pair of blue jeans.  One day you look down and you see a hole around the knee.  Did you tear them… no. The denim just wore out.  Can you imagine trying to sew that fabric back together?

Patients with rotator cuff tears will present with different symptoms or complaints.  To a large degree your symptoms from your rotator cuff tear will depend on the size of the tear, or what percent of the rotator cuff is actually torn.  Small tears will present with pain on the side of the arm, or the front of the shoulder.  Patients will complain of pain with use and with putting the arm in certain positions.  Many patients will have night pain as well.  Patients with large tears may also note significant weakness and they may not be able to raise the arm against gravity. Patients with full tears of the rotator cuff may also have severe pain at night.

 

 

Is an MRI necessary?

In many instances an accurate history and physical exam can lead to an accurate diagnosis — and an MRI is not necessary.  If your exam reveals severe pain and weakness, then an MRI will be helpful to see if your weakness is secondary to pain or an actual tear. Remember, based on your age, you may have had a tear BEFORE your shoulder pain began.  Therefore an MRI can sometimes lead to unnecessary surgical recommendations.

If you have very severe pain, disability and have not improved with non-surgical management then nn MRI can be very useful in the surgical decision making process.  Some tears of the rotator cuff may not be repairable, or have a poor prognosis (may not heal).  If the torn portion has “retracted” or pulled too far away from the bone, a repair will be difficult and the re-tear or recurrence rate may be high.  An MRI can tell us exactly how far the tear has retracted.

Rotator cuff “atrophy and fatty infiltration”…. These are very important prognostic factors when considering rotator cuff surgery.   If the rotator cuff has been torn for a long time the muscle may actually turn into fat (fatty infiltration)!!!   Fat does not contract or act like a muscle, so repairing a rotator cuff tear where the muscles have turned to fat is unlikely to improve your function.   Unfortunately, even if a repair is successful, the fat will NOT turn back into muscle tissue.  An MRI is very useful in determining the degree of atrophy or fatty infiltration.

Bottom line… an MRI can be very useful if surgery is being contemplated, but an MRI is not necessary for all shoulder injuries.

Rotator Cuff Surgery:

       Is Surgery Necessary for all Rotator Cuff Tears?

Without a doubt the literature clearly supports that the answer to this question is NO.  Many rotator cuff tears do not require surgery.   Many, many rotator cuff tears are  small and attritional or degenerative in nature.  That means the rotator cuff tissue simply wore out over time … a long time.  Many patients with small tears can usually be managed with physical therapy, occasional injections, and activity modification.  Some tears will grow in size over time, but many will not.  Therefore, if non-surgical treatment is successful in alleviating your pain, you should still follow up with your surgeon twice a year to be sure the tear has not gotten any larger.

If you try non-operative management and your pain persists— and your quality of life is poor because of the pain, then perhaps rotator cuff surgery, for a repair, is necessary, but this is not the typical outcome for a small attritional tear associated with tendinosis.

Remember:  Even if you are doing well —- some small tears become larger.  We do not know which tears will grow and which will not, so follow-up with your surgeon is important, even if you feel fine.

Traumatic rotator cuff tears are a different story altogether.  If you fell, or suffered a severe injury and notice weakness, loss of motion and severe shoulder pain you should see a shoulder specialist sooner rather that later.  Most active shoulder surgeons favor early rotator cuff surgery for large traumatic rotator cuff tears.  This is because your tissue was most likely normal prior to trauma and therefore the results of surgery should be good with regards to improvement in strength, range of motion and elimination of pain.

       How is Rotator Cuff surgery performed?

The surgery is performed in an operating room.  Some centers will put you to sleep for the surgery, and other centers may simply put your shoulder and arm to sleep with an injection.   Many shoulder surgeons are proficient at arthroscopic rotator cuff surgery.  That means they can accomplish repairing rotator cuff tears arthroscopically...  or through multiple small incisions.  Be sure your surgeon has performed a fair number of these and is very comfortable with the technique.  Many surgeons also continue to fix tears using an open incision.  As long as the surgeon can achieve the same level of success with arthroscopic and open techniques, then  the arthroscopic technique offers a number of advantages — both to you as the patient and to me as the surgeon.

First, the view we obtain using an arthroscopic approach can not equaled. I can place a small camera in places we cannot see through an open incision.  My access is unlimited with an arthroscopic approach since I can move the camera around to see all the other structures in the shoulder to make sure that nothing else needs to be addressed at the same time.

Second, an arthroscopic approach spares the deltoid muscle from being cut and pulled open, which can lead to significant pain and stiffness.

Bottom line … both open and arthroscopic methods of rotator cuff surgery are proven to have similar track records for small rotator cuff tears and medium rotator cuff tears. The main difference is the smaller incision, less trauma, and perhaps a shorter duration on pain medications with arthroscopic rotator cuff surgery techniques.   An arthroscopic approach does NOT change the amount of time in a sling after surgery, nor does it change the fact that you will require an extensive amount of physical therapy after your sling comes off to restore motion, strength, and function.

IF you live in Dutchess, or Westchester County, NY, feel free to click the link below to book an appointment online to explore your options — or call 914-789-2735

 

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DISCLAIMER

Howard Luks MD